Mar 29, 2011

Elderly patients with heart failure who need skilled nursing care after hospital discharge are often sicker, at higher risk for poor outcomes and are more likely than other patients to die or be rehospitalized within one year, according to research reported in Circulation: Heart Failure, an American Heart Association journal.

"Patients hospitalized with heart failure are high risk to start with," said Larry A. Allen, M.D., M.H.S., lead author of the study and assistant professor of cardiology at the University of Colorado-Denver School of Medicine in Aurora. "If they have to go to a skilled nursing facility, patients, families and providers shouldn't be under the impression that life will, necessarily, go back to normal. We should help patients and their families recognize this high risk and adjust their medical decision making appropriately."

Heart failure affects nearly 6 million Americans, and is the primary cause of hospitalizations among Medicare patients. Although many of these patients are discharged to skilled nursing facilities, the type of treatment they receive often varies.

A skilled nursing facility is similar to a nursing home, but can also provide specialized care, such as physical therapy, for patients unable to resume independent living. Skilled nursing patients may by nature face extra challenges, including less mobility, cognitive impairment or poor in-home support ― all of which are determinants to outcomes.

"We don't have a lot of data about the quality of care given in these facilities," Allen said. "This analysis highlights the need to better understand this unique group of patients and the care they receive.

Are they and their families getting information they need to make informed decisions on alternatives to care for short- and long-term prognosis?"

Allen and colleagues analyzed data on 15,459 Medicare patients ― enrolled in the American Heart Association's Get With The Guidelines®-Heart Failure program at 149 hospitals in 2005 and 2006 ― and discharged from the hospital after three or more days of heart failure treatment. Patients' average age was 80, most were white and 55 percent were female. The researchers found that:

About one-fourth of patients were discharged to a skilled nursing facility.

Thirty days post-discharge, 14 percent of patients discharged to skilled nursing facilities had died of any cause, compared to 4 percent of those who returned home from the hospital.

At one year, 54 percent of patients discharged to skilled nursing facilities had died of any cause, compared to 29 percent of patients discharged to home.

Furthermore, there was a higher rehospitalization rate among patients discharged to skilled nursing facilities. Thirty days after initial hospital discharge, 27 percent of patients discharged to skilled nursing facilities were rehospitalized for any cause, compared to 24 percent of patients discharged to home. One year after discharge, rehospitalizations were common in both groups, although the difference between them remained steady, with 76 percent of skilled nursing and 72 percent of home patients readmitted to the hospital.

Patients discharged to skilled nursing facilities were more likely than other patients to be older, female, hospitalized longer and to have other complications in addition to heart failure.

"Even after adjusting for patient differences, a strong predictor of mortality in the next year was discharge to a skilled nursing facility," Allen said. "This has important implications for talking to patients and their families during the initial hospitalization for heart failure.

They need to have clear expectations for survival and rehospitalization. Options for advanced therapies and end-of-life care, including hospice and advanced directives, should be discussed for these high-risk patients."

Skilled nursing use varied by region. The highest rate was in the northeastern United States, where nearly one-third of heart-failure patients left the hospital for skilled nursing facilities. The lowest was in the west, where about one-fourth required this type of care.

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